Candidate Registration Form

CANDIDATE REGISTRATION - RSA 664
CANDIDATE
Last Name:*	First Name:*	Middle:
Name as on Ballot Paper	User Name:*	Password:*
Email:	Phone Number:*
Physical Address:
Street Number	Street Name:*	Address Line2:
Town:*	State:*	Zip:*	-
Mailing Address:( Same as Physical Address )
Street Number	Street Name/ P.O.Box	Address Line2:
Town:	State:	Zip:	-

FISCAL AGENT ( Same as Candidate )
Last Name:	First Name:	Middle:
Occupation:	Place of Principal Employment:
Email:	Phone Number:
Physical Address:
Street Number	Street Name	Address Line2:
Town:	State:	Zip:	-
Mailing Address:( Same as Physical Address )
Street Number	Street Name/ P.O.Box	Address Line2:
Town:	State:	Zip:	-

Indicate the election(s) for which the Candidate is registering:
Election Year:*	Primary General Other
Other:
Party Affiliation:*	Office:*
District:	County: